Thursday, May 29, 2008

I have been writing for many months about our efforts to eliminate central line infections, starting with this post in December of 2006, and then giving periodic updates on this blog. Now, there is a regular feature on the BIDMC website where people can check in on this and other clinical indicators.

But we received a report yesterday that I have to share in this forum again. The chart above shows the year-by-year number of central line infections at BIDMC, as measured in cases per 1000 patient days in our intensive care units. Clear and steady progress over the last several years is evident, and I have to admit that I am really proud of our folks -- nurses, doctors, residents, and others -- in our ICUs.

What does this mean in real terms? Well, in a typical month, there might be 1500 patient days in our ICUs. With a drop in our infection rate from over 4.0 to under 1.0, it means that more than 4 people per month (.003 x 1500) did not get a central line infection. With a mortality rate of, say, 20% among those getting such infections, it means we are saving the equivalent of roughly one life per month.

This also saves lots of dollars, mainly for the insurance companies and governments who pay for the extended stays that result from infections. It also frees up scarce ICU capacity for seriously ill patients who show up in our Emergency Department or are otherwise admitted to the hospital.

What's left? What does it take to get to zero? Frankly, we are not sure. There is no distinct pattern of causality among the cases we still see -- and we evaluate each and every one. I'd love to hear from others out there who have also been successful on this front if they want to offer comments on anything we might want to consider to achieve our ultimate goal of a sustained "zero".

A few weeks ago, we adopted the following policy. I imagine other hospitals have versions of it, but it actually caused some significant debate here before we adopted it. The idea is to help support people who want to devote time to work with medical relief organizations in the US or abroad. Off course, we want to be helpful to folks who want to do that, but the business issue is that it costs our hospital money if we pay people for time off -- beyond their usual earned vacation time -- to do so. So the compromise we reached is that we will pay someone for a week's time every two years, leaving people to use their own earned time beyond that if they want to engage in this kind of volunteer service.

I welcome examples from other hospitals (and, indeed, other nonprofit and for profit businesses) and am curious if our policy on this is more liberal than, consistent with, or more conservative than others'. Thanks in advance for your comments.

Humanitarian Medical Mission Leave

Staff who volunteer for medical missions under the auspices of a recognized relief organization or non-profit organization such as the American Red Cross, Federal Emergency Management Agency (DMAT, VMAT, IMSURT), Doctors without Borders, or similar agencies, may have paid leave of up to 7 working days every two years. This leave is in addition to an individual’s earned time. The 7 days of leave can be taken in increments from one day to seven days over the two year period. Permission for leave is at the discretion of the supervisor and will be dependent on the ability to maintain adequate staffing coverage in the department.

Compensation is based on the staff member’s earned time rate and is prorated based on the compensation received from the relief organization Employees are not eligible to take medical mission leave until after twelve months of satisfactory employment and must be employees in good standing. This policy applies only to benefits eligible employees. Per diems and temporary employees are not eligible.

In addition, staff may be asked by the medical center to support the Metropolitan Medical Response System (MMRS) for community disaster relief. For community MMRS deployment, compensation will be based upon the staff member’s weekly scheduled hours, and local travel expenses will be reimbursed, if necessary.

Our CIO, John Halamka, who is also CIO of Harvard Medical School, does a very fine job on the big issues facing the hospital's and HMS' IT systems, but he is also on call for personal requests. Here is one that he received from one of our faculty members, on which I was copied. Yes, I am poking fun a bit at the person who wrote it, but I have often noticed a tendency of those of us a from a certain era to blame the systems people and/or their computers for our own errors. I plead guilty on that front, also, from time to time!Hey, it's not our fault: Thetechnical devices with which we grew up were pencil and paper, analog clocks, and telephones with rotary dials. For those of you reading who view these as quaint: The first had a delete button called an eraser; the second presented a real representation of time, which after all, is based on the continuous -- not discrete -- apparent movement of the sun around the earth -- not a pseudo-precise digitization of same; and the third will help you understand why people still talk about "dialing" a phone number.

Dear John,

Periodically I check my junk mail box as I learned that the messages from the Dean's Office and general mailings from HMS are there. I suspect that I am not alone in this and feel that it may be one reason why our faculty are not as aware of opportunities and other issues as they pertain to the medical school. Is there a way that these messages can be diverted into our inbox? Probably most people delete the junk box without reading the messages there. Thank you for your attention to this as well as everything else you do.

John's reply:

I asked the Email system administrator to log in to your personal account and provide a listing of the email addresses you've blocked as junk. That list includes several categories including allfaculty@listserv.med.harvard.edu. Thus, you've blocked all email from Harvard (the allfaculty) listing. This block only applies to you, not to other faculty members, so others have received the Dean's emails.

To unblock email from Harvard, launch Outlook, select Tools, Options. The General Preferences tab has a button for Junk Email. Delete the entry for allfaculty. I hope this helps!

Wednesday, May 28, 2008

I had the pleasure last week of attending the opening celebration of the Commonwealth Compact, which has the following mission statement:

To establish Massachusetts as a uniquely inclusive, honest and supportive community of -- and for -- diverse people. To acknowledge our mixed history in this effort, and to face squarely the challenges that still need to be overcome, understanding that the rich promise of the region's growing diversity must be tapped fully if Boston and Massachusetts are to achieve their economic, civic and social potential.

Members of the Compact, which already include over 100 institutions and companies, agree to make certain commitments and participate in data collection about various aspects of diversity (e.g., board membership, staffing, purchasing). These data will be collected and published for the various business sectors. Data from individual companies will not be released in an effort to focus on the collective accountability of the state's business leaders to enhance recruitment, mentorship, and support of women and minorities in the work environment.

At BIDMC, we support these goals, and we like the idea of collective accountability as symbolic of the need for all to work together on these issues for the good of the greater community. However, as is the case with regard to our goals for quality and safety and patient satisfaction in the delivery of health care, we believe that publication of our own progress is an important aspect of holding ourselves accountable. Accordingly, it is our intention to publish our own data on these measures when we submit them for inclusion in the Compact's industry-wide figures. In so doing, we do not in any way mean to undermine the collective reporting model adopted by the Commonwealth Compact, nor in any way seek to create public pressure for others to also release their data outside of that model. While we would welcome that action, our purpose is to send a message to our own boards and our own staff that we hold ourselves accountable to a high standard of commitment on these matters. Where we may fall short, we must -- without casting blame -- share responsibility throughout our organization and let everyone in the hospital know the facts so that we can all acknowledge those flaws and, together, seek ways to improve.

Monday, May 26, 2008

An excellent article by Stephanie Strom in today's New York Times covers what appears to be a growing controversy about the degree to which non-profit organizations should or should not be permitted to be tax exempt under federal and state rules. This is a legitimate area for public debate, and the article sets out a number of examples and points of view.

I do not know much of the history of tax-exempt status, but I am guessing it was given by Congress and state legislatures to certain categories of non-profits in light of their public service obligations and activities. I am personally involved on the boards of several tax-exempt non-profits, including BIDMC, an academic medical center devoted to clinical care, research, education, and community service; MIT, a university; ISO-New England, the organization that supervises the reliability and pricing of the regional electricity transmission system; and the Celebrity Series of Boston, an organization that acts as an impresario to bring concerts to the Boston community and also education programs to children in that region. Previously, I have been on the boards of other tax-exempt non-profits, ranging from the Newton Girls Soccer League and Boston Area Youth Soccer to the Silent Spring Institute, which conducts research about breast cancer. As this list alone indicates, the range of services provided by tax-exempt non-profits is very wide.

Now, if we think about it, any one of these lines of services could be provided by for-profit corporations. Taking my current affiliations in order, there are for-profit hospitals and for-profit colleges; the transmission system used to be run by for-profit utilities; and there are obviously for-profit entertainment impresarios. What does society get out of granting tax-exempt status to these institutions? The most obvious thing is that none of the gains (i.e., "profits") of non-profits are distributed to private investors. They are all recycled into the mission and services of the organization.

Society also gets these services delivered at lower cost. Why? Because the non-profits do not have to pay property tax, sales tax, or income tax and because they can finance their capital needs using tax-exempt debt instead of a higher cost mixture of equity (i.e., stock) and tax debt. Also, they are more likely to receive philanthropic donations to help pay for the services offered. Thus, the underlying cost structure of non-profits to end-users and/or society, everything else being equal, should be lower. (I say should be lower because some people have argued that non-profits are less businesslike and less efficient that for-profit firms in the same lines of business and therefore actually deliver services at a higher cost. Truthfully, I haven't seen much evidence of that, but that is not my argument for today.)

So, here's the big policy question. What would people hope to achieve by actually taking away the tax-exempt status of current non-profits? Putting aside the self-interest of people in for-profits who are in competition with non-profits, this desired outcome has to be driven by the conclusion that society would be better overall by having certain services provided only by taxable organizations, whether non-profit or for-profit. In essence, the goal would mainly be an attempt to create tax revenues at the federal, state, or local level.

But, I think the actual question is more interesting and subtle: What do people hope to achieve by threatening to take away the tax-exempt status of current non-profits? If their goal is not actually to take away the tax exemption, then they are seeking to have these organizations do more of what they feel is appropriate in the way of public service. (I set aside, for today, other purposes for such activity that are designed to achieve results altogether different.)

Currently, the determination of whether an organization deserves tax-exemption is left to the IRS and states' Attorneys General or tax departments. (The Minnesota court case cited in the Times article represents what I believe to be an unusual judicial foray into this determination, but I might be wrong on that front.) The IRS and the others use broad categories of eligibility, as directed by their respective legislatures. When questions are raised, these governmental bodies have the authority to examine programs and records and take away an organization's tax-exempt status.

So, the question I pose for you is this. Are you content with the existing form of rules and regulations covering the applicability of tax-exempt status to non-profits? Does your answer depend on whether you are talking about hospitals, schools, social service agencies, athletic organizations, research institutes, or other categories? (Let's leave religious institutions out of the discussion for today!) If you want changes, what are you hoping would be accomplished? How would you measure success?

Friday, May 23, 2008

Several years ago, following an extensive external and internal review, BIDMC adopted an education strategic plan designed to insure that our training programs would meet high standards of academic and pedagogical rigor. This was suggested to me by our then Chief Academic Officer (and now Dean of Harvard Medical School) Jeffrey Flier, and led by Dr. Richard Schwartzstein, now our VP for Education, and addressed issues of governance, continuous assessment, as well as the usual space and financial concerns. We figured that this part of our three-part (clinical care, research, and education) mission should be held to the same standards we demand of the other two. Please recognize that BIDMC has always been known within the Harvard system as an excellent place for physician training, but we felt that we might have been riding on our laurels a bit and that a more disciplined approach to this area was warranted. The education plan was formally adopted by our Board of Directors in 2004.

Yesterday, I learned of one direct consequence of this coordinated and comprehensive approach. In the world of residency and fellowship programs, the measure of your success in program design and implementation is found in the periodic program reviews by the ACGME and in the terms of renewal granted by that organization. Nine of our internal medicine fellowship programs were reviewed in the last year, and all nine received the maximum term of recertification -- five years. Here they are, with the names of the program directors:

The entire program area in overseen by Dr. Eileen Reynolds, our Internal Medicine Program Director, ably assisted by Dr. Buck Strewler, deputy chief of medicine. As noted by Mark Zeidel, our Chief of Medicine, "It is generally very difficult to do well on one fellowship, but to get perfect scores on all of them is really a tribute to Eileen, Buck and the program directors."

Overall now, 62.5% of BIDMC programs have cycle lengths of 4.5 or 5 years. Congratulations to all, and repeated thanks to Drs. Flier and Schwartzstein for helping to set us along the right path several years ago.

Thursday, May 22, 2008

I don't think that anyone who has read this blog over the past several months or heard me give speeches can accuse me of being anything less than a strong advocate for transparency in the health care system. Nor have I hesitated to publicly disagree with the Massachusetts Medical Society when I feel they are being overly protectionist or conservative in their public policy positions. But I admit to sympathy for the MMS' point of view, as set forth in this story by Jeff Krasner in today's Boston Globe.

As noted in the story, the MMS is suing the state's Group Insurance Commission, which runs the health benefit program for state and local government employees, for a failure to properly rank physicians in tiering them by cost and quality. My sympathy comes from the fact that doctors in our hospital have been improperly ranked based on faulty information and, when they have called the GIC's agents on this matter, they have been told, in essence, "Too bad. We'll fix it next year."

It seems to me that the GIC's intentions are good, but the implementation is flawed. If there is a not a clear and timely procedure for correcting incorrect data about a doctor, the agency is unwittingly providing poor information to the public, undermining its very purpose in providing information in the first place. To the extent patients end up paying higher co-pays to see doctors who are improperly ranked, it is unfair. Finally, the persistent publication of erroneous data undermines the efforts of those of us who are encouraging greater transparency by aiding and abetting the opposition of more recalcitrant members of the medical profession. (And to be clear, I know Dr. Bruce Auerbach, the current head of the MMS, and he is a strong advocate of quality improvement and is definitely not in that "recalcitrant" category.)

The article gives a couple of examples of the problems encountered by doctors in their rankings. I invite other MDs out there to share their stories on this blog.

Wednesday, May 21, 2008

At a combined meeting of the BIDMC Board of Directors and Board of Trustees today, we had an informative presentation from and a pleasant discussion with Massachusetts Governor Deval Patrick. He thanked our Board members for their time and dedication in volunteer service to our hospital and then covered a number of current policy issues, graciously taking time to answer questions on a variety of topics. The Governor has shown a strong interest in health care matters and in the development of the life sciences field in Massachusetts, and our Board members were very appreciative of his taking the time to visit and explain his views in person.

As previously reported, we have a wonderful system that permits doctors to order prescriptions online, allowing patients to pick them up directly from their preferred pharmacy. Recently a friend of mine went to our BID~Needham Emergency Department, and came home with a script to get her prescription from our pharmacy. So I inquired. Our ever helpful CIO, John Halamka, explained:

At present, e-Prescribing in the US is generally limited to primary care practices and specialists who act as primary care givers, i.e. cardiologists, ob/gyns, pulmonary docs, etc. Massachusetts is the number one e-Prescriber in the country, yet only 13% of the routable prescriptions in the state go electronically. BIDMC ambulatory clinics use it, and they are routing 35% electronically, increasing every month.

At BIDMC and BID~Needham Emergency Departments, prescriptions are written electronically and printed to tamperproof paper on laser printers in the department. To my knowledge, there are no Emergency Departments in the state using e-Prescribing. Here's the challenge

1. It is currently illegal to e-Prescribe any controlled substance -- pain killer, sedative, anti-anxiety drug etc. Approximately 1/3 of all Emergency Department prescriptions are of this type. Recently, the Massachusetts Department of Public Health was able to get a DEA exemption to test one site (Berkshire Medical Center using Meditech software) to e-prescribe controlled substances. The DEA wants this to be a three year pilot , which illustrates how resistant to change the DEA can be. I've just signed a letter along with many health care standards and pharmacy leaders urging Congress to get involved and accelerate the ability to e-Prescribe controlled substances as a modification to Medicare Part D standards.

2. The real advantage of e-Prescribing occurs when a patient has an ongoing relationship with the clinician and the renewal workflow can be automated. Emergency Department Physicians do not have ongoing relationships with patients (at least most of the time)

3. In my anecdotal experience, many patients visiting EDs do not have a specific pharmacy preference since their ED care is related to trauma, treatment while traveling, or an acute event requiring a medication, but the patients do not take meds chronically. Hence a tamperproof computer generated paper prescription is most convenient for them.

Tuesday, May 20, 2008

Each year at this time, we conduct a ceremony acknowledging our employees and doctors who have worked 20, 25, 30, 35, 40, and 45 years at BIDMC. This year, almost 300 people had those five-year anniversaries. Two of note are the two doctors show above from our Pathology Department, Harvey Goldman (45 years) and Seymour Rosen (40 years), both well known for their clinical skills and for their teaching abilities. Congratulations and thanks to them and all the others for so many years of dedicated service to the public and our hospital.

I offer this as a public service to help others begin to understand people from Massachusetts. It was sent to me by my daughter, currently an LA resident, who was feeling nostalgic for her Sox and jimmies and the Cape:

You know you're from Massachusetts if . . .

1. You've pulled out of a side street and used your car to block oncoming traffic so you can make a left; 2. Stop signs mean slow down a little, but only if you want to; 3. You know how to cross four lanes of traffic in five seconds; 4. You believe using your turn signals gives away your plan to the enemy; 5. You think it's not actually tailgating unless you're touching the bumper of the car in front of you; 6. You know that a yellow light means that at least five more people can get through and a red one means two more can; 7. The transportation system is known as the "T"; 8. You could own a small town in Iowa for the cost of your house; 9. You almost feel disappointed when someone doesn't flip you off when you cut them off or steal their parking space; 10. There are 24 Dunkin Donuts shops within 15 minutes of your house;

11. When people talk about "The Curse Of The Bambino" you just say "Remember that time the Red Sox made history by coming back from 3 games down against the Yankees and went on to win the World Series?"; 12. (Omitted because of poor taste); 13. If you stay on the same road long enough it eventually has three different names; 14. Someone has honked at you because you didn't peel out the second the light turned green; 15. You have honked at someone because they didn't peel out the second the light turned green; 16. All the potholes just add to the excitement of driving; 17. You think if someones nice to you they either want something or they are from out of town and lost; 18. Six inches of snow is considered a dusting; 19. Three days of 90 degree heat is definitely a "heat wave" and 63 degrees is "on the warm side"; 20. You cringe every time you hear some actor/actress imitate the "Boston Accent" on TV or in a movie -- If you don't have it then you're never going to get it even if you were born here;

21. At the ice cream shop you call chocolate sprinkles "jimmies"; 22. You can go from one side of town to the other in less than fifteen minutes and see at least fifteen losers you went to high school with doing the same thing they were doing when you saw them last; 23. It is raining and/or snowing, the person in front of you is going 70, and you're still cursing them for going too slow; 24. You know how to pronounce towns like Worcester, Haverhill, and Cotuit; 25. You know what they sell at a "packie"; 26.You've called something "wicked pissa"; 27. You've slammed on your brakes to deter a tailgator; 28. You still try to order curly fries from Burger King; 29. You keep an ice scraper in your car all year round; 30. You know at least three Tony's, one Vinnie, and a Frank;

31. Paranoia sets in when you can't see an ATM or CVS; 32. You think crosswalks are for wimps; 33. You've bragged about saving money at The Christmas Tree Shop; 34. You know what "regular coffee" is, and you order iced coffee in January; 35. You can navigate a rotary without a problem; 36. You have been to Fenway Park; 37. You refer to the New York Yankees as the Evil Empire; 38. You feel the rest of the world needs to drive more like you; 39. When someone calls you a "masshole" you take it as a compliment; 40. You use the words "wicked" and "good" in the same sentence;

41. You know what a frappe is; 42. Saint Patrick's Day is your second favorite holiday; 43. You are proud to drink Sam Adams and think that the rest of the country owes Bostonians a thank-you; 44. You never say "Cape Cod" -- You say "the cape"; 45. You went to Old Sturbridge Village and Plymouth Plantation in elementary school; 46. You can drive to the mountains and the ocean all in one day; 47. You have a special place in your heart for the Worcester Firefighters; 48. You know the Mass Pike and 128 are some strange weather dividing lines; 49. You do not recognize the letter "R" as a part of the English language; and 50. You've gone from I-95 South to I-93 North by driving in a straight line and never changing direction.

It has been some time since I wrote about Monique Spencer's excellent book, The Courage Muscle, A Chicken's Guide to Living with Breast Cancer, but this note from a friend prompted me to remind you about it:

Paul,I just read this book. I had to wonder, "Was she with me during my year? Did she sit in on my Dr. meetings? Was she at home with me when all sorts of thoughts were going thru my mind?"You are great to publish that book. It mad me really laugh & also comforted me to know I was not alone in my thoughts. Thanks for printing it.

You can buy the book from Amazon, but if you buy it from the hospital instead, the proceeds go to support Windows of Hope, our non-profit oncology shop that sells wigs, scarves, and other supplies for cancer patients. Just send a check for $20 to Windows of Hope, 330 Brookline Avenue, Boston, MA 02115, and we will mail you a copy. Or call 617-667-1899.

I have reported below on observations by my friend, Dr. Honora Englander, as she traveled in Africa on medical missions. She just arrived home and had these observations. The pictures are hers as well.

Dear friends and family,I sit writing from the Entebbe airport waiting for my departure. Slowly, I am beginning that transition back to a different world. I am surrounded by white people for the first time in five weeks, there are others with laptop computers, and there is no chaos, no clouds of smoke, and the seat next to me is empty (a stark contrast from my most recent bus cross-Uganda bus ride with a large woman cloaked in several robes, her child, and half of her luggage all in my lap!). I am sad to be leaving, having said goodbye to dear friends over the past few days. I will also miss the energy, the heat, and vivid color of life here. At the same time, I am grateful to return to comfort, ease, and every-day security of home that travel has made me appreciate more than ever before.

Sunday morning, eight of us departed for the village of Mifumi in eastern Uganda. The plan was to provide medical care at the IDP camp and at the Mifumi Health Center, a remote center that was founded to support survivors of domestic abuse, but whose role has expanded to provide primary medical care to the surrounding communities. The night before our departure, the Kenyans and I were guests at a lovely dinner hosted by a Fulbright fellow from the National Library of Medicine (part of the NIH) who is living in Kampala. She told us about the health center's recent efforts to promote regional malaria education and shared innovative posters she's developed to teach the general public about causes and prevention of malaria. In simple pictorials, the posters describe malaria signs and symptoms, highlight the role of nets, and debunk village myths that mangoes cause malaria.

We set off eager to see a different part of Uganda, and looking forward to a breather from the hectic city life. Along our journey way we stopped to watch a Manchester United match – an absolute must for the men in the group (most East African men are absolute fanatics for English soccer) – so when we arrived in Mifumi it was after dark. Power was out, beds were scarce, and mosquito nets were nowhere to be found. The grasses surrounding the complex were tall and the place was teeming with mosquitoes, the irony of which escaped none of us. Beautiful posters were ubiquitous, but even at the health center, nothing put into practice. A bit disheartened, I overheard the often repeated and sometimes troubling, sometimes heartwarming phrase – "TIA - This is Africa." We passed the evening under the untouched night sky, used all the bug repellent I had carried in one night, and I listened as students shared stories visits to their "upcountry," ancestral lands.

The next morning, we toured the health center with a lovely volunteer name Ben. Part way through the tour, Ben told us that he is "living positively with HIV" and volunteers with the clinic to help and empower others like him to do so. Humble, dedicated, and sincere, it is people like Ben who make some of the greatest contribution towards reducing stigma around HIV. The few resources at the center were a surprise, even despite my limited expectations. There was a pharmacy that dispensed approximately 40 different drugs, a lab that could perform a total of ten studies, a surgical suite (still under construction) and consultant rooms. After brief introductions, we paired up in teams to see the growing line of patients who had come to see the doctors from Kampala who were visiting the clinic.

The first patient we saw was a soft-spoken and subservient young woman whose husband had been treated for syphilis several days prior. Her husband stood squarely behind her and did most of the talking. As we asked a few basic questions – namely how the husband's diagnosis was made and if either had been tested for HIV – two young women appeared. The nurse introduced them as the man's two other wives. While I watched and listened to the translation from Swahili and English to the local language, I realized that one of the women – though barely showing under her clothes – was pregnant. For those of you not in medicine, congenital syphilis can be associated with severe birth defects and grave consequences. So, together with the students and interpreter we counseled the family, treated all four, and recommended HIV testing, and hoped that the pregnant wife would seek further antenatal care. And so, the day began…

The countryside was beautiful, and I appreciated the chance to stay in the village and see an example of how so many of the patients cared for in urban referral hospitals live. The main mode of transport was by foot or bicycle (didn't see a single car or truck apart from ours the entire time) and the villagers were friendly and outgoing. As anyone who has traveled in Africa knows, the sight of a westerner is enough to elicit bunches of children running from their homes with cries of excitement, and Mifumi was no exception. In Mifumi, women still kneel when they greet men, and the basics of clean water, shelter, and healthcare are far from assured. As it turned out, on our way into the village we learned that the IDPs had left the camp. We were told that in the days preceding, they were given two options – to return home or be relocated to permanent camps in western Uganda. So all that remained were cleared fields along the road with abandoned tent sites marked by stones.

My last day in Kampala had elements of the warmth, kindness, corruption and chaos that echoed throughout the trip. Most notably, it was marked by an unexpected and seemingly crooked phone call I received the day prior, suggesting that I might be "detained" in the country. A few weeks prior when I was at the border visiting a friend, I was approached by two people claiming to be immigration officials (or imposters – hard to tell) who stopped me, claiming that I had a "suspicious face." (Who can argue with that, right?!) At the time, it seemed they were looking for a bribe, and I got out of the situation without bribing or any real inconvenience, as the two guys backed off once the driver of my car called his own boss, who I was told happened to be someone high up in the government who was also the boss of these immigration officials… The details didn't make full sense to me at the time, but I was safe on my way to Kampala and didn't give it much additional thought until the phone call the night before my planned departure. The call was not scary – just unsettling – and unsure of who to turn to for advice, I decided the US embassy was my best bet. So, early the next morning I was off to the US Embassy in Kampala, and like so many of my recent experiences showed me my own country in new light. As an American woman thousands of miles from home, the moment I walked into the gated complex, I crossed into a haven of security and trust. I was met with good counsel, respect, and kindness. And I confess, I even got tearful when "America the Beautiful" came on overhead while I was in the waiting room! I left feeling reassured and informed, and with a deeper understanding of the cloak of safety that I am afforded simply by my nationality.

In the past, as I imagine will be true this time, returning to the US has left me with much to reconcile about the disparate realities of the way we live here and there, about the scale and burden of disease worldwide, and about of costs and benefits of living a culture with so much excess, so much abundance. On a personal level it is much simpler for me, and I leave feeling deeply touched, enriched, and indebted to my African friends and colleagues for their warmth and generosity.

Friday, May 16, 2008

An email letter from a staff member to me. Many, many helpful suggestions that we will work on.

Paul – I have unfortunately have had the experience over the past several months to switch sides from supporting MDs provide care to patients to that of becoming the loved one of a patient. My mom was admitted here on 12/29/08 with what was thought to be a stroke. After five weeks of treatment and the inability to control seizures that she was having every three minutes, it was discovered that it was not a stroke, but instead a Grade IV Glioblastoma.

Since my mom’s first admission, she has been readmitted four other times. In total, I think my mom was an inpatient at BIDMC, 10 out of the past 14 weeks. For family reasons, coordination of her care has fallen to me. We have many supportive family and friends, but at the end of the day it’s just the two of us. Her prognosis is not good. They say less than three months. I never thought I would get to the point where I am o.k. with her passing, but life is not for existing, but living. She is now in long term care and luckily, has only had a few episodes of pain. Anyway, I have written and re-written this email in my head a million times, but seeing your (May 7 SPIRIT update) email today has prompted me to sit down and send you a few of my observations over the last ten weeks. I am sorry this is so long, but each bullet reflects an important point I wish to emphasize.

Here they are:

-- The nurses are phenomenal!!! Time after time, I have been impressed that here is this woman who they only know through my description (one of the results of the tumor and subsequent seizures is that she cannot speak) and the nurses are so dedicated, caring and empathetic. My mom has gone from a woman who walked seven days per week, took down her own fence this past summer and cared for my children to a woman who can’t talk, walk, wears a diaper and has to be fed. They somehow without even trying have time after time preserved her dignity.

-- The coworkers (patient care technicians) are also phenomenal. They do not receive near enough credit. Their jobs are very hard. They lift, roll, clean, feed patients constantly and do so quietly and patiently. They must go home exhausted every night.

-- Communication, communication, communication. If we could find a way to better communicate w/ families, our Press Ganey scores would exceed 90% instantly. I have worked here for 12 years and at times was so frustrated with my inability to find out what was going on. I had instant access to my mom’s oncologist and neurologist, but in most cases, families have to go through residents. The residents are so busy and they usually see the patients first thing in the morning prior to a family member coming. In addition, once you get to know one, they switch services and you have to start all over again. The same thing with medical students. One day over a weekend, I waited eight hours in my mom’s room to speak to a resident. No family member should have to do that. I at least would go into my mom’s record to read the notes (with her permission of course), but people that do not work her do not have that opportunity. If there was a way to block certain sections of OMR (online medical record), but provide families access to others or develop a summary page for family members that would be great.

-- Another issue is communication between specialties. My mom was part of the Neurology Service. She started on Stroke, moved to Epilepsy, then to Neuro. Oncology, then back to Epilepsy and now is back on Neuro. Onc. Did you follow that? I have come to learn that Neurologists are highly specialized. You can’t ask a Neuro Oncologist about your mom’s seizure meds. You have to go to her Epilepsy Neurologist. Depending on what floor you are on, the quarterback varies. My mom was transferred from one floor to another and she ended up with a whole new attending that I had never met. What made it worse was she had one for the weekend and then a new one starting the following Monday because it was a new month. Again, I work here so I knew who to call, but imagine the 80 year old man trying to take care of his wife. Lack of information is so frustrating. There needs to be a better way to communicate with families and patients.

-- Add-on surgical procedures need to be better coordinated. My mom’s biopsy was an add on for a Friday. Room Service forgot to bring her dinner on Thursday night so her last meal was lunch at around 12 noon that day. Pre-op did not come to pick my mom up until Friday at 6:30 pm. We then waiting there for three hours. She did not go into her biopsy until 9:30pm. The surgeon was ready for her at 9 pm, but we had to wait 30 minutes for her Halo to be delivered for the procedure. The surgeon, nurse and anesthesiologist sat there waiting. My mom’s roommate was an add-on for Monday. Her last meal was Sunday at 6 pm. She got bumped on Monday and not taken until 10 am on Tuesday. She did not eat for almost two days.

-- Patient Satisfaction Surveys – Did you know that you receive one for every admission? That means we have received four. I filled out one. There has to be a savings there. Her experience did not change that much between each admission to warrant four separate surveys.

-- We need better discharge planning. I found three medication errors during each discharge and I am not a doctor. I can only imagine the poor family member that does not speak English. On the day of my mom’s last discharge, the intern kindly called me at home and told me she would be discharged by 1 PM to a long term care facility in Hingham. I got there at around 3 PM and was surprised she was not there. I set up her room and waited. I asked the unit coordinator at the front desk about it and she said she would be in the same room and there must be traffic. I went back and waited. I finally called thr floor at the hosital where I was put on hold for about five minutes. Finally, the nurse got on and said she had her all ready to go at 1 pm and they told her she was not being discharged and did not know why. I then asked to speak to who did know and the intern got on, apologized for not calling me and said it would not be until Monday due to the antibiotics that they could not give to her at the rehab. The following Monday, I was on my way to meet her there when I received a page from the case manager that they had to move her to yet another facility because Hingham would not take her. Luckily, I am happy with where she is, but what a fiasco.

-- MDs need to learn how to give options to families. Her Oncologist has recommended no further treatment with hospice. That was a big pill for me to swallow. Our family does not give up. Once I was able to process that I felt pressured by him to sign off on a DNR and agree to “his” recommendation. After I really thought about it, I realized that in fact that there was no decision to make because she was not even eligible for treatment given her low counts. I had to really push back with him. I’m not sure most families would feel comfortable doing that.

-- Case Managers need to meet with families more. When selecting a rehab., I was given a photocopy of a book with rehabs in our area. The case manager had never been to one of them and recommended I go to visit. I have three children, another family member needing support, a husband, a mother with a brain tumor and full time job. When was I going to do that? This was going to be the place my mom would probably die. I wanted it to be excellent. It would have been helpful if she or another case manager could provide me with some information on the facilities, i.e. the DPH report, testimonials from other patients, etc.

-- Families need to understand the financial implications of recommended treatments and care. Her doctor recommended long term care with hospice. What he neglected to say is that although hospice is covered, long term care room and board is not. This means that if she is not eligible for nursing care or rehab. we have to pay room and board of over $300/day. Luckily, my mom has savings for this, but I was not made aware of this until I sat down with the Head Nurse at the long term care facility.

Wednesday, May 14, 2008

Our head of pharmacy, Frank Mitrano, likes to say that he wishes that all drugs were packaged in exactly the same sized containers, with covers and lids of the same color, and with simple black lettering on a white background in the same font. Why? Because it is human nature to assume that a vial of medicine with a green cap and green lettering is, in fact, the medicine you were looking for, even if it is something quite different. And, also, the more layers of safety protection information systems and other technology that you have in place, the more likely you are to assume that you have the correct drug and the less likely you are to read -- in detail -- what the label actually says before administering the drug to a patient. On the other hand, if every vial were to look exactly the same, a human being would actually have to carefully read what is in it before administering a drug.

Here's the particular story that led Frank to say this today. Don't worry. No harm was done to any patient. But when we heard the story, there was some quick breathing.

Our obstetric service, like all others, uses Oxytocin to induce labor when it is necessary during childbirth. The service had made a practice of stocking each labor and delivery room with a vial of this medicine, in case it would be needed in a hurry. By mistake, one day, the wrong vial of medication was placed in each room. Instead of Oxytocin, a drug called Zemplar, generic name Paracalcitol, was placed in each room. Zemplar is a drug that suppresses the production of the thyroid hormone in a person. Giving a mother Zemplar instead of Oxytocin in the middle of labor would have been quite bad.

The good news is that a nurse noticed this error in one of the L&D rooms before any of the wrong medication was used, and she quickly notified everybody to check all the other rooms and take out the wrong medicine and replace it with the right one. Congratulations to her for her attentiveness.

But how could this happen in a hospital focused on reducing medication errors? Well, in the stockroom rack, medications are grouped alphabetically by generic name on the shelves. So Oxytocin and Paracalcitol are near each other. And look at the bottles above. Zemplar is on the left, and Oxytocin in on the right. Or is it the other way around? They are remarkably similar. So, it might have been a simple stocking error in the pharmacy which then cascaded down the distribution system until the wrong box was delivered to L&D, where the wrong vial was put in each room.

Multiple opportunities for error. In case you have wondered, yes, both the pharmacy folks and the L&D folks have been informed of this particular case. And steps have been put in place to make sure it does not repeat.

Meanwhile, in part of the hospital we have already replaced the manual stocking shelves with a computer controlled electronic stocking carousel that is designed to reduce this kind of error. And we will add this feature elsewhere, too. And, we are also moving towards bar-coding of every single dosage of medication so that it can be matched with the written order and the bar code on a patient's ID band.

But every electro-mechanical system has some flaw. The biggest flaw is that it creates an impression of security and precision that becomes a crutch upon which the medical staff relies. Frank Mitrano is not going to get his wish. So, ultimately, it will still be the responsibility of every single nurse and doctor to actually read the label on each dosage, compare it to the order given, and make sure each patient gets the right medication. Every time. Hundreds of thousands of times per year.

Tuesday, May 13, 2008

A recent report on the SPIRIT log shows that process improvement can show up in unexpected ways. Nice to see residents using it, too! We prefer that they spend time with patients rather than dealing with red tape. With an organization of our size and history, we can expect bureaucratic glitches to show up a lot.

Location of Problem: Employee Health & Emergency Department

Problem: I was recently splashed in the operating room and directed by employee health to have my labs drawn in the ED since it was 4:30pm. In the ED, my vitals were taken and my blood was drawn by an RN. The triage nurse of the ED confirmed that obviously there would be no bill sent, yet about 2 weeks later I received a bill from both the ED Department and the ED Physician for almost $600. After speaking with employee health, I was told this happens "all the time" and I can expect to receive another bill or two but they would work on getting the charges reversed - but it would not be immediate.

Suggested Solution: Better coordination between employee health and ED billing. First, the billing for an occupational exposure should not occur, but if it does, the reversal of charges should be immediate. I shouldn't have to waste my time and continue to follow up through a cycle of bills. I should be able to contact the billing department and have a zero balance as soon as the report of the error occurring.

Person Describing Problem: Vijay Saluja (Anesthesiology Resident)

Root Cause: Vijay, thank you for calling this out. I can address the BIDMC ED charging issue. You are correct that the charges should not have been billed to you for an occupational exposure. There are provisions for covering those cases. Thanks to your call out we have identified a system bug that caused the BIDMC charges to be billed to you and to others in error, and the inconvenience caused is regretted. Martina Comiskey, Revenue Cycle Systems and Training.

Solution (after investigation): Billing system configuration issue causing BIDMC charges to bill to patients instead of Workers Comp Coverage. Needs to be resolved to prevent future incidences. Retroactive report of all impacted patients needed. All accounts need to be corrected and the charges appropriately redirected.

Action Plan (who, what, by when)WHO: Revenue Cycle Systems team

1) BIDMC billing system bug fix - completed 5/8/082) Retroactive reporting will be completed 5/9/083) All patient accounts will be corrected by 5/12/084) Monitor monthly to ensure that process is working as intended.

I'm writing this out of frustration. The door C334 to the male locker room in the Shapiro OR has been dysfunctional for weeks. You need an access card to open it. The mechanism is faulty and each morning for some time now surgeons, techs etc have had to battle to get in the room and change for the OR.

Efforts have been made to 'repair' the mechanism but nothing has worked.

Please forward this to the appropriate person and have them leave the door unlocked till such time as it can work effectively. People have had to force the door open at times which is causing more damage ( to the door and shoulders).

I just don't know who is in charge of this kind of thing but am sure you can forward it to the appropriate authority.

Response from our head of maintenance a few hours later:

Dan Kendall from our offices was approached on this issue directly and has already both assessed the problem and rectified it. In essence, a staff member had taken it upon himself to tape (surgical tape) the latching mechanism so as to avoid having to use his swipe card for access to the locker room. Some of the adhesive residue remained within the moving parts of the mechanism even after the tape was removed.

Dan was able to locate the individual who admitted to taping the mechanism and agreed not to bypass this (or any other) security measures again. Dan was also successful in removing all remaining sticky residue, and the latching mechanism is once again fully functional.

Monday, May 12, 2008

A year ago or so, I wrote about the introduction of our Triggers Program, a rapid response team approach to patients on medical floors who might soon decompensate or have other serious changes in their condition. The program has been incredibly successful in reducing mortality and morbidity. In fact the number of "codes" on our floors has gone down so dramatically that residents now need to practice emergency resuscitation mainly in the simulation center because so few actual patients need it.

I recently asked a couple of our folks who were deeply engaged in the design and implementation of this program -- Dr. Michael Howell and Patricia Folcarelli, RN, Ph.D. -- to tell me what lessons have come out of the last year's experience with Triggers. Here is what they sent me. I offer it in the spirit of sharing information with people in other hospitals.

In the year after implementation of the Triggers program, one of the major focuses of our reviews was on patients who had major adverse events happen in spite of the Triggers program. When these adverse events occurred, we tried to understand the factors that contributed to them even being possible in our organization. A few months after Triggers began, we began to notice some patterns. Here are some examples of the things we learned.

Oxygen is not a utility

Patients in the hospital sometimes need extra oxygen. Low oxygen levels in the blood can be due to pneumonia, heart failure, or a number of other problems. Surprisingly, extra oxygen usually does not help with the feeling of shortness of breath, but rather prevents further problems from not getting enough oxygen to vital organs. We found that, in many cases, providers often treated oxygen as a utility -- like the water that comes out of the sink – rather than as a drug used to support a feeling organ system. (The members of our Triggers Steering Committee had worked in about twenty other hospitals total, and we all felt it was the same in every hospital in which we’d ever worked.)

We saw a pattern in which providers would repeatedly increase the amount of extra oxygen that was being provided to patients. We often monitor the oxygen level in the blood through a noninvasive device -- as his number was normal, providers felt reassured – not taking into account the fact that the patient was needing higher and higher levels of artificial support to keep this number at the “right” level.

In fact, interns would sometimes round in the morning and would find their patients on oxygen with no explanation, and the patient had been breathing room air the night before. Sometimes, neither the nurse nor the intern knew why the patient got put on oxygen; it had happened overnight and was viewed as an unimportant event.

As a result of this we conducted a Failure Mode Effects and Criticality Analysis, a tool used in the military and industry to understand points at which complex systems are likely to fail, and implemented substantial changes in the ways that we order oxygen, in a way that patients are monitored from a respiratory standpoint. We also introduced physician, nurse, and patient care technician education on this matter.

Aspiration risk

We also learned that aspiration was a bigger threat to patient safety than was usually appreciated. When physicians and nurses talk about "aspiration" they are talking about when a patient swallows something the wrong way. This can be the person's own saliva and secretions or, more commonly, can occur when they try to eat or drink something. Since the mouth is usually full of bacteria, this can lead to pneumonia; sometimes, the person actually swallows his or her stomach acid in the lungs, which can lead to very severe chemical injury to the lungs. In some cases, aspiration leads to death. For this reason, when we think that someone is at high risk for aspiration, we put them on “aspiration precautions." This means that nurses, patient care technicians, and physicians are all alerted to the increased risk of this problem. In addition, we put a sign up on the patients at the patient's bedside to warn visitors and those providers who may be seeing the patient before seeing the chart.

As we dug a little deeper into some of these cases, we learned that patients sometimes aspirated food that their families brought in. Family members obviously did this out of love, but it sometimes led to very severe consequences for their loved one. When we tried to figure out why this happened, we found that our warning signs depended heavily on written English, rather than on easily interpretable symbols. This meant that if family members came to visit and English was not their first language, or if they had trouble reading English, we might not convey the right information to them. In coordination with a provider education campaign about the risks of aspiration, we therefore redesigned our signage to overcome these barriers – by using multiple languages and universal symbols (think Mr. Yuck!) that were likely to be interpretable even if the family member was unable to read the sign -- see above.

Who does what?

As inpatient medical care has become more complex, more people are needed to provide it. For example, our nurses do a number of safety checks as they're preparing various medications because these medications have inherent risks. There is also substantial amount of documentation that nurses have to do for safety, compliance, and legal reasons. This means that nurses need extra manpower to get work done. Most hospitals, therefore, have a group of providers who are variously known as nursing assistants, nurse’s aides, or patient care technicians. These providers are trained by the hospital, and sometimes by external schools, but are not licensed in the same way that nurses and physicians are. Patient care technicians may check vital signs, help with turning patients, assist with toileting, etc. In our hospital, for example, many of the routine vital signs are taken by patient care technicians. The Triggers program taught us a few things about patient care technicians and their relationships with our other existing systems of care. In particular, when we did our initial education for the Triggers roll out, we forgot to include patient care technicians in the educational campaign. This was a huge oversight, which we quickly learned when we would see patients who did not Trigger even though they had abnormal vital signs. Why didn't they Trigger? They didn't Trigger because we forgot to provide education to this very important a set of providers in our institution. Once we had included them in the educational campaign, this mechanism of Trigger failure essentially vanished.

We also learned that what patient care technicians do on any given floor is extremely variable. We therefore began a program to help standardize the scope of practice for patient care technicians at BIDMC.

Unintended consequences of improving patient satisfaction

A few years ago, as we tried to improve patient satisfaction, we changed the way that patients order their hospital food. The program was called “At Your Request" and let patients call up to order their meals from a menu of options – at essentially anytime they wanted to eat. (From a practical standpoint, this works a lot like room service: you call and order your meal, and it shows up half an hour later.)

However, this turned out to be another way that patients who were at high risk for aspiration (see above) could get food that was unsafe for them to eat. A patient on aspiration precautions, for example, could literally call and order a hamburger, which would generally be delivered, warm and tasty, a half hour later. When we saw events related to this, we redesigned the process by which food was delivered, creating an electronic Diet Dashboard and directing the delivery of all food for patients on aspiration precautions to the nursing station. (Sometimes, patients at high risk for aspiration just need help eating food safely, which we can now provide.)

If the nurse is worried, you should be worried too.

This is an example where our analysis confirmed something we already believed to be true.

The Triggers Program has various specific criteria mandating a response from providers. For example, if the pulse rate is acutely greater than 130 beats per minute, a Trigger is called and the team responds. However, we have one criterion which is much more subjective: "marked nursing concern." When we implemented the Triggers program, many physicians were very nervous about giving this criterion. They were afraid that they might be called in the middle of the night for things that weren't really important, and that nurses might use this as a weapon if they did not like the physician or if they disagreed with the plan of care.

Well, it turns out that nurses use this Trigger quite judiciously – only 15% of our Triggers are called only for nursing concern. (In another 27% of cases, nurses express “marked concern” but the patient also meets other criteria simultaneously.) It also turns out that if nurse has “marked nursing concern,” it means you’re really sick. The in-hospital mortality rate for a patient who has a Trigger called for “marked nursing concern” is 10.7%.

This is roughly twice as bad as showing up to the Emergency Department with a heart attack. Literally.

Friday, May 09, 2008

If you are in Cambridge, please visit the BAAK Gallery at 35 Brattle Street to see the paintings of Kathryn Sanfilippo, a Boston-based (450 Harrison Avenue) artist displaying paintings inspired by her time in Italy. The one above is called Countryside and gives you a sense of the colors and broad brush strokes used by Kathryn. The show opened tonight and goes until June 5, when the Italian Consulate presents it at the Federal Reserve Building.

P.S. Health care folks in Atlanta and Columbus might recognize the last name, also associated with brother Fred, CEO of Emory's Woodruff Health Sciences Center and Chairman of Emory Healthcare, and formally Senior Vice President for Health Sciences and Dean of the College of Medicine at Ohio State University. Fred is the first to admit, though, that the real talent in the family lies with his sister.

Remember when I told the story about using Lean process improvement techniques to enhance the service in our orthopaedic clinic? That was over a year ago.

Here's a note from a recent patient, a local student:

I just had to share this with you because it was such a neat feeling at the time. I saw Dr. Gebhardt yesterday (my orthopaedic surgeon) and there there was no wait for anything at all. Checking in was a breeze. I saw Dr. Gebhardt exactly on time. Afterwards, I was worried about getting the x-rays because the whole waiting room was full, but again, there was no wait. I've read about lean, SPIRIT, and process improvement on your blog, so it was such a neat feeling to experience and also to know what was behind my no wait experience! I think it provides a whole new meaning to patient-centered care. The only thing that was odd was that the front desk never asked me to pay...but I was so happy with my visit that I actually offered to pay my copay (and this is coming from a poor graduate student).

Dr. Michael Kahn, from our Department of Pyschiatry, has published an article in the New England Journal of Medicine that suggests that doctors enhance their relationship with patients when they deal with patients in a polite manner. Here is a summary on the AOL web site, along with a poll on the issue. I like this summary: Etiquette-based medicine . . . "would put professionalism and patient satisfaction at the center of the clinical encounter and bring back some of the elements of ritual that have always been an important part of the healing profession."

NEJM has published the entire article as freely available to the public here. This is a very polite thing for them to have done, and I thank them.

As each new class of interns arrives at the hospital, it is important to provide a context for their experience. Most of their advice and training comes from their clinical leaders, but the CEO has a role, too. Here are excerpts from one of my notes to the current class:

Dear Interns,

I'd like to turn to some important matters facing BIDMC and explain your role in helping us achieve some very important goals. The context is this: While you as doctors -- along with others who have come before you -- have received excellent training in biology, disease, diagnostics, and treatment, there is a growing part of clinical care that requires all of us to expand our scope and consider the manner in which we actually deliver care and how we might improve that. Our hospital has decided to be a leader in the science of care delivery, reviewing and enhancing our overall system of care to reduce harm to patients.

Several months ago, our Board of Directors voted to set an audacious goal for BIDMC, to eliminate preventable harm over the next four years. See theseentries on my blog for more details. Our chiefs of service are fully in support of this goal and are now engaged in many measures to make it happen. We know of no other hospital in Boston that has taken on this challenge, and there are likely very few throughout the country. It is a bit daunting. But we believe that we have a lot to learn and a lot to teach by making the effort.

Part of the context for setting this goal is to hold ourselves accountable to the public and ourselves. We have been the leaders in this region in transparency of our clinical outcomes, for we believe that self-reporting of medical errors and process improvement is a sure statement of our commitment to progress in this arena.

We have also established an overall process improvement program called BIDMC SPIRIT, in which you will be trained after your arrival. Here's the introductory message about this program. The concept is simple -- to encourage people throughout the organization to call out problems as they see them and to solve them to root cause -- rather than creating work-arounds that just add layers of poorly designed process in the organization. Here are a couple of examples to give you the idea.

I look forward to having you join us as we invent and implement these programs and eliminate preventable harm for our patients.

Thursday, May 08, 2008

Interesting post by Bill Ives, referring to comments by Andrew McAfee at Harvard Business School about Enterprise 2.0, about trusting bloggers, and the role of blogs in business communication. Bill and Andrew and Jessica Lipnack, also cited in the post, are key observers and thought leaders in this arena. Jessica asked yesterday whether email is obsolete. See the last paragraph in a related story on that topic below.

Tuesday, May 06, 2008

Here are some comments made after today's BIDMC SPIRIT training session (see some of the participants above). We are now winding down on training the first 600 people. As you can see, people quickly get to the core issues, problems, and opportunities. This is about where we expected to be at this point in the process. After all, we are introducing new concepts of empowerment, problem identification, and problem solving -- and sometimes people are confused or nervous. The suggestions from these trainees are exceedingly helpful. But look, too, at the last comment: Key messages are starting to come through. Then, see a bit of my analysis after the comments.

We noticed when logging our issue that you see “SPIRIT problems.” We think it would be better to look at “SPIRIT opportunities.” One idea we had was to change the language.

On the issue of what are appropriate call outs, several of us were talking earlier today that there seems to be some confusion out there about what it’s OK to call out and who can do it. At the beginning, it seemed that it could be about anything and everything and the staff would be empowered … then there seemed to be a reassessment and it became in some areas there are some things you can call out and some you can’t … that you have to go through the manager and the body language suggests whether this is going to go forward or not … and I think there are varied answers to these things depending on who’s speaking from the help chain.

How to fix this? I think just a reaffirmation of the goals and key principles to the entire leadership team, so that it is not interpreted in various ways by various leaders. In some places, staff aren’t allowed to touch the log without talking to the manager. We know we are trying to find our way and it’s early.

Talking about the “chain of command” has a connotation of fear in some places. Where we were, these were perhaps more junior nurses than in the PACU and they didn’t want to identify anything as a problem … it seemed they were fearful. For us, residents, it can be hard to call something out. We need an environment where all are equal and our insights are encouraged.

We’ve trained all the managers and supervisors and not the front line in this way because that would be overwhelming but perhaps we could do an in-service DVD that just lays out the key principles that this is all about. Staff are reading about this on the web, they are hearing things second hand, but if you (Paul Levy) could deliver the message it might help with the consistency of the message as well.

A big thing is … just because it happens all the time doesn’t mean it should. We see all of these problems. 10 minutes here. 20 minutes here. People think they are little. But they add up quickly. For those of us who are out there, they add up quickly to patients’ lives. 1 life. 2 lives. They may seem small but they aren’t. They matter. People need to understand that.

We started our journey toward eliminating hunting and fetching for every BIDMC staff member 8 weeks ago. We are consciously following the path trod by other large organizations in other fields (Toyota, Alcoa, US Navy submarine corps) that seem to do what their peers do to far superior results, in terms of staff satisfaction, quality, and business performance. The core of our approach is empowering everyone at BIDMC to call out when they hit a glitch in their work (see the problem) and participate in understanding the problem and developing solutions. We are learning how to provide the right level of help to them right away (swarm the problem), then how to share improvement stories transparently throughout the hospital.

Overall, we stand about where I expected, but some of the particular challenges we have are interesting.

We have plenty of evidence that it is right to involve each employee more deeply in problem solving, every day. Story after story has surfaced about how the people who do the work have pointed to the solution that could work – and is more likely to endure. Just last week, the housekeepers and unit staff in an ICU developed a solution to a chronic shortage of pillows needed to prop up their patients that has been driving them crazy for years.

We also are seeing the value of immediately investigating specific instances of problems, while the details are fresh. Using the observed details of what just actually happened keep us on the right track in a way that far-off committee meetings of folks who may not actually do the tasks being discussed may not.

And while we are still in the infancy of learning how to share effectively, people are picking up not only specific solutions from the SPIRIT log, but also insights on how to solve problems.

And people are paying attention. The SPIRIT log is often viewed more than 1,000 times a day, and my reports from SPIRIT here on this blog are being tracked by people around the world eager to learn with us.

So that is good, but we are still far from where we want to be in the breadth and quality of problem solving that will really make life as good as it could be for our staff. That’s what we expected at this stage of things, but it underlines how much work we have to do. What are the challenges on which we should focus at this starting stage?

First, the quantity of hunting and fetching investigation and solution attempts we are seeing is not even a small fraction of the challenges we know staff face on a daily basis. This is not a numbers game, but we do want to see much more high quality problem solving occur. Every person at BIDMC has something to offer (and gain) to understand this dynamic in their own areas, but here are some of the forces at work.

(1) It’s clear that in many places, it doesn’t feel “safe” for staff and managers to have problems in our areas being called and worked in the transparent light of SPIRIT. This sense is critical to overcome. When people feel more comfortable to bring opportunities to the surface and work them in plain sight, we will make the most rapid progress. It is the areas where I am not seeing any SPIRIT call outs that I worry about the most at this point.

(2) Some of us are so used to working around problems that we don’t even recognize that there is an opportunity to make the work easier. Some managers are countering this by actually walking next to staff as they do their work and helping them see what may be a “work around” and where there is opportunity. That works and can be helpful in these initial stages.

(3) Many people don’t really believe their boss wants to hear about their next hunting and fetching episode “in real time.” People have been implicitly rewarded in the past for solving impediments by brute force, and they think their leaders may not welcome reports of a “small” problem. After all, the managers are busy, too. We need to reaffirm that the responsibility rests with supervisors to actively encourage those who look to them for leadership to begin calling out opportunities to them in person. Of course, we won’t be able to work on every problem in real time until we get a lot better and faster at this, but we need to start.

(4) Some people don’t yet know how to “call out” in the most productive way. We need specific reports of specific problems, without blame. We need people to stick to the facts. And we need reports made in person to the immediate supervisor, not entered directly on the log unless no one is available to help.

Second, I see lots of opportunity to deepen our solutions, so that we are not only solving the immediate problem, but also applying the lessons to similar situations. For example, if CT radiology residents didn’t have an easy way to realize they were sometimes presenting their technologists with protocols that conflicted with the original physician orders (a “connection” problem), how many similar situations exist across our clinical services? We plan to begin pushing on these issues as we progress.

Third, though we are pleased with the orientation and training we have provided to almost 600 managers, staff have told us that they need more direct exposure to the SPIRIT principles and tools. We will expand efforts in this area shortly.

It turns out that new mothers are particularly at risk for back injuries for a while after childbirth because of hormonal changes. Kathleen Shillue, one of our physical therapists, has prepared this short video called "Handling the baby without hurting yourself," to help people avoid injury. Please check it out.

Monday, May 05, 2008

I received this wonderful report from Blanche Murphy, Nurse Coordinator for the Central Line Service, who knows of my interest in eliminating central line infections. Be sure to check out the site she mentions for an excellent educational tool.

Dear Paul,

I want to share with you a very positive recent experience that I have had at the medical center. Knowing how much you believe in team spirit, I feel that my story is a wonderful example of many people from several areas of the medical center coming together to produce a resource enabling our patients to have safer and knowledge based care. Although many of the functions were done independently, it took all people I mention to produce the outcome.

Three years ago I had an idea to develop a pictorial index on-line allowing staff to correctly identify central venous lines and their appropriate care. It would also serve as an educational tool providing diagrams and pictures to further enhance understanding of central venous access. At the time of this idea, I also initiated a practice change reducing the concentration of heparin we give our patients that would effect the information being given but also entailed major changes to our on-line pharmacy ordering system . On April 16th we went live with a very involved change in the POE system and the debut of the central venous line educational tool.

From the start there were many people who provided their expertise to make this goal achievable. Rich Stroshane from Operations took all of the pictures and Davin Janicki from Healthy Care Quality/ Process Improvement worked endless hours helping put the images into an on-line format. Andy Mackler P.E.V.A. Consultant from Venous Access contributed all the information in regards to PICC lines. Karen Smethers from Pharmacy worked several hours with me establishing a correct ordering system with generated flushing orders for the multiple number of lines we place in our patients. Steve Maynard, Jean Beach, David Feinbloom MD, Jean Hurley from IS, and Kim Sulmonte from Patient Care Services also gave much of their time. Media services' Christophere Ruhle (no longer employed here) and Oran Barber assisted in putting on the final touches to obtain a professional system . Lynn Darrah and Justine Carr were major catalysts for bringing the project to a successful completion with an effective roll out. Although each member of this team developed contributions on their own, it was only when each part worked to together with a team spirit for the final product that the launching could happen.

At http://home.caregroup.org/centralLineTraining/ you can see for yourself how wonderful the outcome was. By selecting a picture you will be able to view more in-depth information with a link to flushing guidelines insuring a quick reference for staff immediately available. The POE ordering under IV Therapy/IV Access orders also provides not only the correct flush orders for multiple lines but also another way to link to the educational tool.

As I said this was an idea I had three years ago, and if not for the tremendous team work and support from various areas across the medical center it would have never been successfully carried out.